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SAN JOAQUIN COUN• <br /> j ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E. Hazelton Ave., Stockton • CA 95205 <br /> \. a q (209)468-3420 • Fax:(209) 468-3433 • Web;www.sigov.org/ehd <br /> �<1Foac?i <br /> -+ EMERGENCY RESPONSE RECORD <br /> 3 <br /> DATE: b—////�� )o SHORTTER #: <br /> PREMISE DDRESS: -q ` CITY: <br /> DBA: 4Nder1 CROSSSTREET: <br /> PREMISE OW NER: PHONE: <br /> OWNEWS ADDRESS: qq CITY: 2 <br /> FACILITY CONTACT: V'UVDY PHONE: <br /> RESPONSIBLE PARTY(RP)DBA: <br /> RP NAME: PHONE: <br /> RP ADDRESS: CITY: <br /> RP CONTACT: PHONE: <br /> NATURE OF RESPONSE(explosion,spill,leak,fire,or abandoned/dumped mat ial) <br /> TIME RECEIVED: TIME OF ARRIVAL: TIME OF DEPARTURE: 1� <br /> PERSONS AT SCENE <br /> NAME AGENCY PHONE TOA TOD <br /> 0- SJC EHD q-Q 3- 3' r tknm <br /> e Ia er ryl� 510- 96 <br /> Ci A baa 3 -- <br /> MATERIAL/CLASSIFICATION laemiauxvanol <br /> IDENTIFICATION SPILLED? SOLID LIQUID GAS COMMENTS <br /> (LBS) (GAL) (Cu m <br /> j o <br /> u o <br /> j o <br /> o ❑N <br /> n ON <br /> ❑Y ❑N <br /> REFERRALS AND NOTIFICATIONS <br /> REFERRED TO(NAME AND ADDRESS) DATE MAILED <br /> DATE PROP 65 COMPLETED: 3` 6-'4Kl DATE UAR COMPLETED: <br /> IF PERSONS EXPOSED and/or INJURED,"PERSONAL TOXIC SUBSTANCE EXPOSURE RECORD"COMPLETED? ❑ YES ❑ NO <br /> ER BINDER COPIES: <br /> SHORT-TERM ON TOP ARRATIVE MAP ANALYTICAL DATA PROP 65/UAR ❑ ILE CREATED <br /> MANIFEST ❑ REFERRALS ❑ CLEAN UP REPORT ❑ OTHER AGENCY REPORTS 1 ❑ EXPOSURERECORD PHOTOS <br /> ER RECORD Page 1 10/03/12 <br />